Botulism

Botulism

Botulism is a Notifiable Condition.

Botulism is a rare but serious bacterial infection caused by a toxin that attacks the body’s nerves and can lead to breathing problems, muscle weakness and death.   This toxin is made by Clostridium botulinum and sometimes Clostridium butyricum and Clostridium baratii bacteria.  The toxin can be produced by these bacteria in food, wounds and the intestines of infants. 

There are five main types of botulism:

• Infant botulism can happen if the spores of the bacteria get into an infant’s intestines.  These spores grow and produce the toxin which causes illness.
• Wound botulism can happen if the spores of the bacteria get into a wound and make a toxin.  People who use injectable drugs have a greater chance of getting wound botulism.  Wound botulism has occurred in people after a traumatic injury, accident or surgery.
• Foodborne botulism can happen by eating foods that have been contaminated with the botulinum toxin.  Foodborne botulism are often found in homemade foods that have been improperly canned, preserved, or fermented.  While uncommon, store-bought foods can also be contaminated with botulinum toxin. 
• Iatrogenic botulism can happen if too much botulinum toxin is injected for cosmetic reasons such as; wrinkles, migraine headaches or other medical reasons. 
• Adult intestinal toxemia (adult intestinal colonization) botulism is similar to that of infant botulism.  This very rare kind of botulism can happen if the spores of bacteria get into an adult’s intestines, grow and produce the toxin.  People who have health conditions that affect the gut are more likely to get sick with this type of botulism. 

Botulism is extremely serious. All types of botulism can be fatal and are medical emergencies.  If you or someone you know has symptoms of botulism, seek medical attention immediately.

Symptoms

Signs and symptoms may include:

• Difficulty swallowing
• Muscle weakness
• Double vision
• Drooping eyelids
• Blurry vision
• Slurred speech
• Difficulty breathing
• Difficulty moving the eyes

Possible signs and symptoms of foodborne botulism might also include:

• Vomiting
• Nausea
• Stomach pain
• Diarrhea

Signs and symptoms in an infant may include:

• Constipation 
• Poor feeding
• Drooping eyelids
• Pupils that are slow to react to light
• Showing less facial expression than usual
• Weak cry
• Difficulty breathing

It is important to note that someone with botulism may not experience all of these symptoms at the same time. 

If you or someone you know has symptoms of botulism, seek medical attention immediately.

Treatment

Botulism is a rare but serious bacterial infection caused by a toxin that attacks the body’s nerves and can lead to breathing problems, muscle weakness and death.   

Doctors treat botulism with a drug called an antitoxin.  Antitoxins prevent the toxin that is attacking the body from causing any more arm.  The antitoxin does not heal the damage the toxin has already done.  Depending on the severity of your symptoms, you may need to stay in the hospital until you are well enough to return home. 

Prevention

Infant botulism

Most infant botulism cases cannot be prevented because the bacteria that causes the disease is in soil and dust. The bacteria can be found inside homes on floors, carpet, and countertops—even after cleaning. For almost all children and adults who are healthy, ingesting botulism spores is not dangerous and will not cause botulism (it’s the toxin that is dangerous). For reasons we do not understand, some infants get botulism when the spores get into their digestive tracts, grow, and produce the toxin.

Honey can contain the bacteria that causes infant botulism, so do not feed honey to children younger than 12 months. Honey is safe for people 1 year of age and older. Learn more about infant botulism from the Infant Botulism Treatment and Prevention Program.

Wound Botulism

Prevent wound botulism by keeping wounds clean. If wounds appear infected, seek medical care quickly. A wound might be infected if it is:

• Red
• Swollen
• Painful
• Warm to the touch
• Full of pus or other drainage
• Accompanied by fever
  

Not all wounds with botulism show these general symptoms of a wound infection. If you have a wound and begin to have symptoms of botulism, seek medical care immediately.

People who inject illicit drugs, such as black tar heroin, are more likely to get wound botulism than people who do not inject drugs. People who get botulism from injecting illicit drugs might not have an obviously infected injection site.

Foodborne botulism (Create drop down)

Many cases of foodborne botulism have happened after people ate home-canned, preserved, or fermented foods that were contaminated with toxin. The foods might have become contaminated if they were not canned (processed) correctly.

If you preserve, can, or ferment your own foods, you can reduce the chance of these foods giving you, your family, or others botulism by:

• Follow safe home canning instructions as recommended by the U.S. Department of Agriculture in the USDA Complete Guide to Home Canning
• Following all instructions for washing, cleaning, and sterilizing items used in canning
• Using pressure canners for low-acid foods like potatoes, most other vegetables, and meats
  

Everyone can reduce their chances of getting botulism by:

• Refrigerating homemade oils infused with garlic or herbs and throwing away any unused oils after 4 days.
• Keeping potatoes that have been baked while wrapped in aluminum foil hot (at temperatures above 140°F) until they are served, or refrigerating them with the foil loosened.
• Refrigerating any canned or pickled foods after you open them.
  

Iatrogenic botulism  

You can prevent iatrogenic (an illness caused by medical examination or treatment) botulism by getting injections of botulinum toxin only by licensed practitioners:

• If you need an injection of botulinum toxin for a medical condition, your doctor will choose the safest dose.
• If you get an injection of botulinum toxin for cosmetic reasons, be sure to go to a licensed professional.
  

Adult intestinal colonization

Adult intestinal colonization (also called adult intestinal toxemia) is a very rare type of botulism. People who have health conditions that change the structure or proper workings of their intestines (gut) may be at higher risk. Only a handful of people have been diagnosed with adult intestinal toxemia, and scientists do not fully understand how a person gets this type of botulism. It may be similar to infant botulism, which cannot be prevented.

For Health Care Professionals

• If you suspect your patient may have botulism, call Chelan-Douglas Health District at 509-886-6400 immediately.  If there is no answer, contact Washington State Department of Health (DOH) Office of Communicable Disease Epidemiology (CDE) (877-539-4344 or 206-418-5500).

If clinical consultation supports botulism, request antitoxin immediately and begin treatment as soon as it is available.  DO NOT WAIT for laboratory confirmation.  If administered early in the course of illness, antitoxin can prevent progression of illness and shorten its duration. 

Specimen Collection

• For stool testing, submit at least 15 grams of stool, if possible 50 grams (ping-pong ball sized). If the patient is constipated, as is common with botulism, a small amount (5-30 cc) of sterile, nonbacteriostatic sterile (not tap) enema water and non-glycerin-containing suppositories may be used. For post-mortem testing, collect multiple 15-gram stool specimens from different parts of the small and large intestine.
• For serum testing in an adult, submit at least 8 ml of serum (not blood), 10 ml preferred. Extra serum from other tests may be used if collected before treatment. For children other than for infant botulism (stool testing), minimum is 4 ml of serum.
• For food testing, send as much implicated food as available in the original containers. Typically only open containers are tested, not others from a batch. Rinsed jars have tested positive. Pack each item individually in sterile unbreakable securely sealed containers
• For wound testing, send wound swab or tissue for culture in anaerobic transport medium. Anaerobic cultures from another laboratory can also be submitted for identification.

All specimens should be kept refrigerated (not frozen) during storage and transport. Use cold packs to maintain a shipping temperature of 4o C (39o F). Specimens must be properly packaged using guidelines for shipping and packaging of diagnostic specimens. Be sure to use absorbent material around the primary container, particularly food specimens, which could have high levels of toxin and present a danger if there is leakage. Include a completed DOH Reference Bacteriology form with specimens.

Legal Reporting Requirements

• Health care providers and Health care facilities: immediately notifiable to local health jurisdiction (link to CDHD notifiable condition page)
• Laboratories:  immediately notifiable to local health jurisdiction; submission required – presumptive positive isolate or if no isolate available specimen associated with presumptive positive result, within 2 business days. On request of a public health agency, send diagnostic specimen(s): serum (food or wound botulism) or stool (food or infant botulism); also include as requested by DOH or LHJ any other specimens available (i.e., implicated foods, debrided tissue or wound swab).
• Local health jurisdictions: suspected and confirmed cases immediately notifiable to the Washington State Department of Health (DOH) Office of Communicable Disease Epidemiology (CDE) (877-539-4344 or 206-418-5500).

Adult cases: The following are the steps to be taken for notification (suspected or confirmed cases):

1. Health care provider: Immediately notify Chelan-Douglas Health District the patient’s history and physical exam findings, particularly neurologic exam findings (e.g., cranial nerve function).
2. Chelan-Douglas Health District notifies Washington State Department of Health (DOH) Office of Communicable Disease Epidemiology (CDE) (877-539-4344 or 206-418-5500). 
3. CDE will discuss botulinum antitoxin with CDC. 
4. CDE calls CDC, CDC and provider decide about antitoxin treatment.

Infant cases: The following are the steps to be taken for notification (suspected or confirmed cases):

1. Health care provider: Immediately notify Chelan-Douglas Health District the patient’s history and physical exam findings, particularly neurologic exam findings (e.g., cranial nerve function).
2. Chelan-Douglas Health District immediately refers provider to California Department of Health Services at 510-231-7600, www.infantbotulism.org for consultation and BabyBIG®
3. Chelan-Douglas Health District immediately contacts CDE 877-539-4344 for diagnosis.
4. LHJ and CDE arrange testing if patient is being treated – urgent

Treatment should never be delayed pending laboratory confirmation.

Please note that it is important to act quickly and follow the above steps to ensure timely and appropriate treatment.

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Additional Resources

• WA DOH Botulism, Adult Guidance
• Centers for Disease Control and Prevention
• Foodborne Botulism Reporting Form
• Infant Botulism Reporting Form (PDF) (wa.gov)
• Wound Botulism Reporting Form (PDF) (wa.gov)
• Protect Yourself from Botulism

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